Primary care physicians are on the frontline when it comes to mental health issues in children and adolescents. With a burgeoning patient population, and ever fewer child psychiatrists to support them, primary care physicians are increasingly called upon to diagnose and treat these conditions despite the lack of formal training.
First, the scope of the problem. Dr. Amy Cheung reported the rates of depression and suicidality (suicidal ideas and/or attempts) in adolescents 15-18 using Statistics Canada data1. The total population surveyed was 38,500, of whom 2,866 were adolescents aged 15-18. The diagnosis of a major depressive illness was based on a structured interview using DSM-IV criteria (see Table 1). Cheung estimated lifetime prevalence for a major depressive illness at 7.6% (adolescent females) and 4.3% (adolescent males). The suicidality rate was 13.5% overall, 8.8% (adolescent males) and 18.4% (adolescent females).2 Surprisingly, only about 50% of adolescents committing suicide have been previously identified as depressed.3
This survey doesn’t tell us about the prevalence of milder forms of depression in this population. In my province of Quebec, suicide is the second highest cause of death in adolescents after accident. Farand et al showed that 78% of Quebec adolescents who committed suicide were seen in a medical facility for a medical problem in the year before the suicide. However, only 12% received psychiatric help and only 9.9% saw a psychiatrist (population studied = 435 suicides, < 19 years of age in 5-year period, 1992-1996) indicating that the depression was not identified during the encounter with a health care professional.4 Clearly, we need to do a better job of identifying and treating these kids.
What can primary care physicians do? Early identification and intervention is key. A good clinical history is best accompanied by a standardized questionnaire based on the DSM-IV criteria for depression. There are many such screening tools, such as the Achenbach Child Behavior Checklists, Columbia Depression Scale, Pediatric Symptom Checklists, Child/Adolescent Screen (CAPS), Beck Depression Inventory and others. I recommend going to the Canadian Pediatric Society (CPS) website, www.cps.ca and navigating to Mental Health: Screening Tools and Rating Scales. The Mental Health Task Force of the CPS has reviewed a large number of these screening tools for pediatricians and family physicians. The list provides the website for downloading the instruments with comments on each one’s usefulness in particular problems. For a thorough analysis of these various assessment instruments, see Brooks and Kutcher’s review.5 Another useful resource for the busy physician is the tool kit, Guidelines for Adolescent Depression in Primary Care, GLAD-PC, Tool Kit. This tool kit and its recommendations were the result of a joint task force involving experts from the Center for the Advancement of Children’s Mental Health at Columbia University, Sunnybrook Health Sciences Centre at the University of Toronto, the New York Forum for Child Health and the American Academy of Pediatrics. The tool kit can be downloaded for free by going to www.glad-pc.org .
Glad to be of service
Based on the available evidence, the GLAD coalition made the following recommendations regarding identifying youth at risk: “Patients with depression risk factors (such as a history of previous episodes, family history, other psychiatric disorders, substance abuse, trauma, psychosocial adversity, etc.) should be identified and systematically monitored over time for the development of a depressive disorder (strength of recommendation: very strong).”3
With regard to diagnosis, the task force’s recommendation is: “PC (primary care) clinicians should evaluate for depression in adolescents at high risk as well as those who present with emotional problems as the chief complaint. Clinicians should assess for depressive symptoms on the basis of diagnostic criteria established in the DSM-IV… and should use standardized depression tools to aid in the assessment (grade of evidence A; strength of recommendation: very strong).”3
It’s important to assess for suicidal thoughts or intentions and the fourth recommendation of the task force suggests establishing a safety plan should the teenager deteriorate; this includes a ‘911’-type line for emergencies for the adolescent/family. The task force also recommends interviewing parents or teachers to help formulate the diagnosis.
Once a diagnosis is made then the initial management consists of monitoring and supporting the teen and his/her family. The general practitioner can educate the patient and family, and develop a treatment plan with specific goals, i.e. the adolescent refusing to go back to school may have as a goal to start back at school incrementally, perhaps 1 or 2 days per week initially. Written action plans have been shown to be very useful in the management of asthma, and by analogy should be helpful for the treatment of depression. Collaboration between all the partners in the child’s life is important: primary care physician, family and school.
The GLAD-PC Tool Kit can provide you with useful algorithms and flow charts for the diagnosis and management of depression and I highly recommend it if you need some entry point into this vast topic. Next month, we’ll review the recommendations of the GLAD task force regarding effective treatments.
Richard Haber, MD, FAAP, FRCPC is an associate professor of pediatrics at McGill University and the Director of the Pediatric Consultation Centre at the Montreal Children’s Hospital.
5 or more of the following symptoms present in the same 2-week period signal depression: